Myocardial infarction in a low risk patient with hereditary hemorrhagic telangiectasia

We describe the case of a 57 year-old woman with NSTE ACS, a history of recurrent and prolonged epistaxis, and low prior cardiovascular risk. Additional findings revealed anemia and an aneurysm in her central nervous system. During her hospital stay, hereditary hemorrhagic telangiectasia (HHT) was diagnosed. After application of two antiplatelet drugs, the patient was scheduled for coronarography, followed by coronary artery bypass grafting. During her hospital stay, only a minor episode of epistaxis was observed. We conclude that anemization due to HTT may significantly accelerate the progress of ischemic heart disease, resulting in acute coronary syndrome. Moreover, coronarography preceded by routine application of two antiplatelet drugs seems not to increase the risk of hemorrhage in HHT patients complicated with myocardial infarction. (Cardiol J 2010; 17, 2: 189-191

Stroke and TIA mimics in patients referred to a neurological emergency department by non-ambulance physicians, ambulance physicians and paramedics

Introduction. Our aim was to compare the structure and management of conditions mimicking acute cerebrovascular events (ACE) defined as stroke or transient ischaemic attack between patients referred directly to a neurological emergency department (ED) by non-ambulance physicians, ambulance physicians and paramedics. Methods. This is a retrospective study of 802 consecutive patients referred to a Polish urban neurological ED with a prehospital suspicion of ACE between January and December 2014. Results. After proper neurological assessment, ACE was excluded in 258 (32.2%) patients. The ratios of neurological to non--neurological ACE mimics were similar across all groups (35:93 for non-ambulance physicians, 22:39 for ambulance physicians, and 28:39 for paramedics). The most frequent conditions mimicking ACE were vertigo (14.0%), headache (9.7%), seizures (7.0%), blood hypertension (7.0%), electrolyte and metabolic disturbances (5.4%), infections (4.7%) and syncope (4.3%). There were no major differences between patients with ACE-mimics referred by ambulance physicians and referred by paramedics in terms of demographic, previous medical history, extent of diagnostic workup, final diagnosis or further management (neurological admission in 42.6% and 28.4% of cases). However, the characteristics and management of ACE mimics referred by non-ambulance physicians were slightly different, including a lower need for hospital admission (neurological admission in 21.5% of cases). Conclusions. There seem to be no major differences in the structure, early diagnostic approach or management of ACE mimics between referrals from ambulance physicians and ambulance paramedics, which provides reassurance to healthcare systems that rely solely on paramedics. Mimics referred by non ambulance physicians appear different in structure and are less resource-consuming

Statement by a Working Group conceived by the Polish National Consultants in Cardiology and Neurology addressing the use of implantable cardiac monitors in patients after ischaemic embolic stroke of undetermined source

Introduction. Stroke remains one of the main causes of death and the most common cause of long-term disability in adults. Embolic strokes of undetermined source (ESUS) amount to a significant proportion of all ischaemic strokes. Detection of atrial fibrillation (AF) in this group of patients would allow for a major therapeutic decision to switch from antiplatelets to oral anticoagulants and therefore significantly reduce the risk of recurrence. State of the Art. Current technology allows long-term continuous ECG monitoring with different systems, including implantable cardiac monitors (ICM). However, in Poland lack of reimbursement does not allow their use in everyday clinical practice. Clinical Implications. This is a statement by a Working Group conceived by the Polish National Consultants in Cardiology and Neurology addressing the use of ICM in patients after ischaemic embolic strokes of undetermined source. The aim was to develop reasonable and comprehensive guidance on how to select and manage candidates for ICM in order to obtain the maximum benefit for Polish public health. Future Directions. This expert opinion is not intended as a guideline but it provides advice as to how to optimise the potential use of ICM in patients after ESUS in the Polish setting

Is there a bad time for intravenous thrombolysis? The experience of Polish stroke centers

Background and purpose The outcome in acute stroke strongly depends on patient-related issues, as well as on the availability of human and diagnostic resources. Our aim was to evaluate safety and effectiveness of intravenous alteplase for stroke according to the time of admission to the hospital. Materials and methods We analyzed the data of all acute stroke patients treated with alteplase between October 2003 and December 2010, contributed to the Safe Implementation of Thrombolysis for Stroke registry from 27 Polish stroke centers. According to the time of admission we distinguished between: (1) non-working days (Friday 14:30–Monday 08:00 plus national holidays); (2) out-of-office hours (non-working days plus 14:30–08:00 during working days); and (3) night hours (time from 23:00 to 06:00). Patients admitted during regular working hours (Monday 08:00–Friday 14:30, excluding national holidays) were used as the reference. Results Of 1330 patients, 448 (32.5%) were admitted on non-working days, 868 (65.3%) at out-of-office hours, and 105 (7.9%) during night hours. In multivariate logistic regression, none of the evaluated periods showed association with symptomatic intracranial hemorrhage, 7-day mortality, and neurological improvement ≥4 points in the National Institutes of Health Stroke Scale score at day 7. Patients admitted during night hours had lower odds (OR 0.53, 95% CI: 0.29–0.95, p=0.032) for achieving favorable outcome (modified Rankin Scale score 0–2). Conclusions There is no bad time for thrombolysis. Stroke centers should feel confident about the treatment outside regular working hours, irrespective of equipment and staff availability. However, it may be reasonable to pay additional attention during nighttime

Sex-related differences among ischaemic stroke patients treated with intravenous thrombolysis in Poland

Aim of study. We investigated sex differences i n i schaemic s troke p atients t reated w ith i ntravenous a lteplase. Clinical rationale for study. We suggest that it is necessary to improve care for women with atrial fibrillation. Our data suggests that closer evaluation of treatment for ischaemic stroke in men and women is needed, preferably in the form of a prospective study. Materials and methods. This was a multicentre analysis of 1,830 ischaemic stroke patients treated with alteplase from 2004 to 2012. Data was prospectively collected in the Safe Implementation of Treatments in Stroke (SITS) registry. The main outcome measures were symptomatic intracerebral haemorrhage (sICH) within 36 hours of treatment, three months of functional independence, and mortality. Results. Women were significantly older (mean age 71.3 vs 66.2 years; p < 0.01), more often suffered from hypertension (78.3% vs 70.1%; p < 0.01) and cardio-embolic strokes (34.7% vs 27.1%; p < 0.01), and presented heavier baseline deficits. There were no differences in sICH, but after three months fewer women were functionally independent (46.5% vs 53.3%; p < 0.01) and women had higher mortality (26.0% vs 19.7%; p < 0.01). Conclusions. Of the ischaemic stroke patients treated with intravenous thrombolysis, women had worse long-term outcomes than men. This discrepancy may be explained by the older age and higher proportion of cardio-embolic strokes with more severe baseline deficits. However, multiple logistic analysis did not show that sex itself had an impact on the greater mortality in women after a stroke, or on the poorer prognosis

Stymulacja kory ruchowej w leczeniu bólów neuropatycznych

Background and purpose Despite the rapid development of neuropharmacotherapy, medical treatment of neuropathic pain (NP) still constitutes a significant socioeconomic problem. The authors herein present a group of patients treated with motor cortex stimulation (MCS) for NP of various types and aetiologies. Material and methods Our cohort included 12 female and 11 male NP patients aged 53 ± 16 treated with MCS. Eleven patients were diagnosed with neuropathic facial pain (NFP), 8 with hemi-body neuropathic pain (HNP), and 4 with deafferentation pain (DP). Prior to surgery, 16 out of 23 patients were treated with repetitive transcranial magnetic stimulation (rTMS), with a positive response in 10 cases. Pain intensity in our group was evaluated with the visual analogue scale (VAS) one month before and three months after MCS implantation. Results Improvement on the VAS was reported in the whole group of patients (p < 0.001). The best results were reported in the NFP group (p < 0.001) while the worst ones were noted in the DP group (p = 0.04). Anamnesis duration positively correlated with outcome. Infection forced the authors to permanently remove the system in one case. There were no other complications in the group. Conclusions Minimally invasive, safe neuromodulative treatment with MCS permits neuropathic pain control with good efficacy. The type of neuropathic pain might be a prognostic factor.Wstęp i cel pracy Pomimo dynamicznego rozwoju neurofarmakoterapii, leczenie bólów neuropatycznych stanowi istotny problem socjoekonomiczny. Autorzy przedstawiają grupę chorych leczonych metodą stymulacji kory ruchowej (motor cortex stimulation – MCS) z powodu bólów neuropatycznych o różnym obrazie klinicznym i etiologii. Materiał i metody W grupie 12 kobiet oraz 11 mężczyzn w wieku 53 ± 16 lat zastosowano MCS z powodu bólu neuropatycznego. U 11 chorych rozpoznano neuropatyczne bóle twarzy, u 8 chorych połowiczy ból neuropatyczny, a u 4 chorych – ból deaferentacyjny. U 16 chorych przeprowadzono próbną przezczaszkową stymulację magnetyczną, uzyskując przejściową poprawę u 10 z nich. Nasilenie dolegliwości bólowych oceniano z wykorzystaniem wzrokowej skali analogowej (visual analogue scale – VAS) miesiąc przed implantacją oraz w trzecim miesiącu po implantacji MCS. Wyniki U wszystkich chorych w grupie stwierdzono poprawę mierzoną VAS (p < 0,001). Najlepsze efekty leczenia bólu neuropatycznego zaobserwowano w grupie chorych z neuropatycznym bólem twarzy (p < 0,001), a najsłabsze u chorych z rozpoznanym bólem deaferentacyjnym (p = 0,04). Długość wywiadów korelowała dodatnio z wynikami leczenia. U jednego chorego ze względu na zakażenie usunięto system i nie podejmowano próby ponownego wszczepienia. Innych powikłań w grupie nie stwierdzano. Wnioski Wykorzystanie minimalnie inwazyjnych technik neuromodulacyjnych, w tym MCS, pozwala na skuteczne i bezpieczne zmniejszenie nasilenia bólów neuropatycznych. Rodzaj bólu neuropatycznego może mieć znaczenie rokownicze

Carotid intima media thickness and blood biomarkers of atherosclerosis in patients after stroke or myocardial infarction

Aim To test if circulating levels of markers of inflammation, endothelial function, and chronic infections, as well as association between these markers and carotid intima media thickness (CIMT), depend on the stage of atherosclerosis expressed as a history of a major vascular event. Methods The associations were analyzed separately in 75 healthy controls, 79 patients 3-6 months after the first-ever non-cardioembolic ischemic stroke (IS), and 37 patients 3-6 months after the first-ever myocardial infarction (MI). Data were collected prospectively in 2005. We measured high sensitivity C-reactive protein (hs-CRP), procalcitonin, E-selectin, intercellular adhesion molecule-1 (ICAM-1), serum level of immune complexes (IC), and identified antibodies against Herpes simplex virus type 1 (HSV), Cytomegalovirus, Chlamydia pneumonia, and Helicobacter pylori. Correlations with CIMT were determined using Pearson R and verified after adjustment for age, sex, hypertension, diabetes, and statin therapy. Results Median ICAM-1 concentration was significantly lower in controls than in post-IS patients (188 μg/L vs 215 μg/L), and significantly lower in post-IS patients than in post-MI patients (215 μg/L vs 260 μg/L). Control patients also had significantly lower IC level (0.03 U/L) and HSV antibody index (6.0) compared to both post-IS (0.6 U/L, 9.6) and post-MI (0.4 U/L, 9.2) patients. CIMT was correlated with age (Pearson R = 0.38, P = 0.001) in the control group, immune complexes (R = 0.26, P = 0.023) in the post-IS group, and with hs-CRP (R = 0.40, P = 0.017) in the post-MI group. These correlations were confirmed using multiple regression analysis. Conclusions Our study supports linear correlations between CIMT and IC and hs-CRP levels. However, these associations seem to depend on the type of vascular burden

External quality monitoring facilitates improvement in already well-performing stroke units: insights from RES-Q Poland

Introduction. The Registry of Stroke Care Quality (RES-Q) is used in Poland for quality monitoring by numerous hospitals participating in the Angels Initiative. Our aim was to assess the degree of improvement in highly stroke-oriented centres that report cases to the RES-Q each year. Material and methods. This retrospective analysis included Polish stroke units that from January 2017 to December 2020 contributed to the RES-Q at least 25 patients annually. Results. Seventeen out of 180 Polish stroke units reported patients each year (2017, n = 1,691; 2018, n = 2,986; 2019, n = 3,750; 2020, n = 3,975). The percentage of ischaemic stroke patients treated with alteplase remained stable (26%, 29%, 30% and 28%, respectively). The door-to-needle time progressively decreased, from a median 49 minutes to 32 minutes. The percentage of patients treated ≤ 60 minutes and ≤ 45 minutes significantly increased (from 68% to 86% and from 43% to 70%, respectively), with no change observed between 2019 and 2020. Despite a general improvement in dysphagia screening (81%, 91%, 98% and 99%), screening performed within the first 24h from admission became less frequent (78%, 76%, 69% and 65%). In-hospital mortality significantly increased (11%, 11%, 13% and 15%), while the proportion of patients discharged home remained stable. Conclusions. Quality-oriented projects facilitate the improvement of stroke care, even in centres demonstrating good baseline performance. Polish stroke units that consistently reported cases to the RES-Q demonstrated improvement in terms of door-to- -needle time and dysphagia screening. However, there is still a need to shorten the time to dysphagia screening, and carefully monitor stroke unit mortality following the COVID-19 pandemic